03010164 t CITY OF CUPEION
BUILDING t CONTRACTOR INFORMATI 0,
BUILDING DtvlStoPERMIT _ Ing le-fiolp9m
a BUILDINGADDRESS: HOT WATER INC 10
19361 GREENWOOD
OWNER'S NAME: 2531 GRACELAND AVE APPLICATION SUB DATE
ldh JOHN REN 01/28/2003
141 ONE: (650) 298-8494
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB M[CH
Ho_ LICENSED CONTRACTORSDECLARA'1'[ON
D D
Rwu I hereby atllrmmat l am liaMsod ender,pm,i:ionsref chn,am v aommenemg Job Descripti gp:B� ..wn I
Zta with Section lOMpof DivisiunJof the Business and Profcainni Qvle.andmyliccnu is R_ '�"�lim(L®
za=p hicensemClass erm`'t REPLACE WATER HEATER k+�
yaZ License Claes Lic.p
OZ—, Dao Contractor
oC a I understand my planss shall he used a6CuLARAIOH FEB 1 3 2003
dV R
f3u.g m
LiccnscJProsainnal BUILDING
HBO OWNER-BUILDER DECLARATION B
I hereby affirm that I am exempt from the Contractor's License Law for the
a a
00 following reason.(Section 7131.5.Business and Professions Code:Any city or county
which requires a Ix:emit to construe,alter,improve,demolish or repair any structure
prior it)its issuance.also requires the applicant for such pemnlo rile a signed statement
that he is licensed pursuant in the provisions of the Cuntmctors License Law(Chaptcy9 Sq. Ft. Floor Area ,}`VjQIIOn
¢ (commencing with Section 7000)of Division of the Business and Poocesiuns Code)or
i 3$ that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than fiw hundrep dollars(S50B. e10 0 Occupancy Type
1,as owner of the porWity,at my employees with wages as their sole compensation,
will do the work,and the suucmre is not intended or offered for sale(Sec.70,14,Business
and Pmfeaions Code:The Contractors Licemc Law does not apply to an owner of 506 — GAS TE Plquire nspec tons
properly who WiMsor improves themon,and whodues such work himxeBor through his
own employees,provided that such improvements are not imended orotiered for side.If, 507 — FINAL PLUMBING
however,me building or improvement is sold within one year Mcompletion,the owner
builder will have the burden of proving that he did not build of improve for purpose of
sale.).
❑1,as owner of the property,am exclusively contracting with licensed conuacmrs to
nstmet the project(Sec 1004,Business and Professions Code:)The Convenor's Li.
cenm law does not apply to an owner of proWny who Wilds or improves thereon,and
who contmca for such pmjecu with a conuactorts)licensed pursuant to the Contractor's
License Law.
❑ l am exempt under Sec. ,B&P C far this reason
1E]
wner Dare
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penally of Perjury one of me following declarations:
I have ami will maintain a Ccnifmcate of Consent selfari mforWorker'sCompen-
ion,as provided for by Section 31(1(1 of the labor Code,for fire pertormance of the
rk for which this pmmit is issued.
I have and will maintain Worker's Compensation Insuance.as required by Section
01of the labor Codc,for the performance of the work for which this permit is issued.
y Worker's Compensation Insurance carrier and Policy number am:
rrier: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This aceion need nut he completed it the permit is fin one hundred dollars(S 100)
or Icsx.)
I cenify that in the performance of the work for which this permit is named.I shall not
employ any person in any manner so as to became subject to the Workers''Compensation
Laws of Cahfmnia.Data
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption.you should
become subject to the Workerh Compensation provisions of the labor Code,you must
OO forthwith comply with such provisions or this permit shall he deemed mvnked.
Z h CONSTRUCTION LENDING AGENCY
[-. 1 hereby affirm that there is a tlmslluction lending agency for the performance of
ai the work for which this permit is issued(Sec.3097.Civ.C.)
alender's Name
Z) Z Lender's Addma
U Q 1 ecnify that 1 have read this application and smte that the above m1nmmion is
g� F'^ correct 1 agree to comply with all city and county ordinances and state laws relating In
�U building construction,and hereby amhorim representatives of this city to enter upon the
above mentioned furinspection whichpuriefies,
F S (We)agree to save,indemnify and keep harmless the City of Cupertino against
hxbN in
or the coarsing ft his eswhichmayinany way acerae againasail City
U in mmneyucncc of the graining of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT Issued by: Date
SOURCE REGULATIONS.
Stgnamre of ApplicanUConvaeor Uate Re-rok6f
ofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will me applicant or future building occupant store or handle ha'reNous material
as dc1iZdction by th255e Cu(a)pertino Municipal Code,Chapter 9.12,and the Health and Safety
Crede.Se ?
El Yes 32C]No All roofs shall be inspected prior to any roofing material being installed.
Will thea applicant or future Wilding nccu ant use a preen If a roof is installed without first obtaining an inspection,I agree to remove
pp g n qui aloy Management
$
it bxeorJnus air contaminants a defined by the Bay Arca Air Quality Management all new materials for inspection.
❑Yes ❑No
I have read the hosallom msterials requimmcnu under Chapter 6.95 of the Califon
7ishic'?
Health&SdctyCov,Seen.25505,25533 and 25531.1 un&t. that if the building
not currently hale a tenant,mat it is my responsibility to notify the occupant of me
uirements which must W mel prior bre issuance ofs Certificate of O:cupancy
Signature of Applicant Date
wneromammmrmmaagentDac All roof coverings to be Class "B"or better